Hyperthermic intraperitoneal chemotherapy in prevention of gastric cancer metachronous peritoneal metastases: a systematic review

Gastric cancer progression resulting in metachronous peritoneal metastasizing is almost always associated with an adverse prognosis. This review discusses various options of preventing metachronous peritoneal metastases in radically operated gastric cancer patients. Also examined are different hyperthermic intraperitoneal chemotherapy (HIPEC) regimens employed in gastric cancer treatment, postoperative morbidity and mortality rates and long-term treatment outcomes. The authors also review their own experience of using HIPEC based on the combination of cisplatin and doxorubicin in doses of 50 mg/m² at 42 °C for 1 h to prevent gastric cancer peritoneal dissemination. As a result, progression-free survival rose from 19.6%±5.6% to 47.1%±6.3% (P_log-rank <0.001) and dissemination-free survival-from 22.7%±6.0% to 51.9%±6.3% (P_log-rank <0.001). It is noted that the combination of the described HIPEC regimen with systemic chemotherapy helped raise metastases-free 3-year survival rate to up to 91.0%±9.0% (P_log-rank =0.025) compared with 48.6%±6.4% for patients who underwent only a combined surgery/HIPEC treatment. HIPEC is a promising combined treatment strategy for radically operated gastric cancer patients that can improve patient survival and decrease peritoneal dissemination rate. However, the number of randomized studies on adjuvant HIPEC are still insufficient for a subgroup assessment of efficacy of the given chemotherapy regimens and generation of evidence-based recommendations on the individual use of chemotherapy agents and their combinations, and HIPEC procedural techniques. Further prospective randomized studies are needed to assess the practicability of complementing HIPEC with adjuvant systemic chemotherapies.

Long-term results of a single-center prospective randomized trial assessing efficacy of a shortened course of adjuvant chemotherapy after radical cystectomy in patients with locally advanced bladder cancer

Introduction

This study assesses the efficacy and tolerability of two cycles of adjuvant chemotherapy (AC) with gemcitabine and cisplatin after radical cystectomy in patients with a high risk of progression of muscle-invasive urothelial bladder cancer as compared to chemotherapy at relapse, in a prospective randomized study.

Material and methods

From 2008 to 2013, all patients after radical cystectomy at our institution for primary or recurrent urothelial bladder cancer with stage pT3-4 and/or pN+ on histopathology and without contraindications to combination cisplatin-based chemotherapy, were randomized either to two cycles of gemcitabine and cisplatin chemotherapy or to follow-up and chemotherapy at the time of relapse. The study endpoints were overall, cancer-specific, and disease-free survival.

Results

The study included 100 patients, of whom 53 received AC and the other 47 were assigned to the control arm. Out of 53 allocated to AC arm, 16 patients did not start chemotherapy or received only one cycle of AC. The median follow-up for patients in the AC and control arms was 88 and 86 months, respectively. In the AC arm the hazard ratio for death from any cause, death from bladder cancer, and disease relapse were 0.70 (95% CI 0.45-1.11; p = 0.13), 0.84 (95% CI 0.50-1.41; p = 0.51), and 0.77 (95% CI 0.46-1.28; p = 0.31), respectively.

Conclusions

Two cycles of AC with gemcitabine and cisplatin in patients with high-risk urothelial bladder cancer after radical cystectomy does not improve overall, cancer-specific, and disease-free survival. Only 53% of patients randomized to AC received the entire planned treatment.

Hyperthermic intraperitoneal chemotherapy in serosa-invasive gastric cancer patients

BACKGROUND

Evaluation of hyperthermic intraperitoneal chemotherapy (HIPEC) in reducing metachronous peritoneal metastases (MPM) risks in patients with resectable serosa-invasive gastric cancer.

MATERIALS & METHODS

Between 2008 and 2016, 154 patients with gastric cancer (stage IIB-IIIC) were randomly assigned to two groups: 76 patients underwent HIPEC (cisplatin 50 mg/m² + doxorubicin 50 mg/m², 42 °C, 1 h) combined with radical surgery (HIPEC group) and 78 patients underwent only radical surgery (control group).

RESULTS

Evaluation of HIPEC toxicity showed neither toxic complications of IV-V degree nor haematological toxicity (according to CTCAE v. 4.03). There was no significant difference in the rate of complications between the two groups (p = 0.254). There was a more frequent disease progression in the control group than in the HIPEC group: 42/55 patients (76.4%) vs. 36/68 patients (52.9%), respectively (p = 0.009). At the same time a significant decrease in the rate of MPM was observed after HIPEC administration as compared with surgery alone - 16/68 (12.8%) vs. 39/55 (27.6%) (p < 0.001). 3-year progression-free survival was 47% (95% CI 36-61)) in the HIPEC group and 27% (95% CI 17-43) in the control group - p = 0.0024. The N-stage, HIPEC procedure, type of surgery and interaction between HIPEC treatment and age were independent prognostic factors.

CONCLUSIONS

HIPEC appears to be helpful in improving treatment results in radically operated gastric cancer patients.

[Management of patients with kidney cancer without distant metastases]

The paper provides the analysis of treatment outcomes in 199 patients with local renal carcinoma. The highest effects were achieved in radical surgery followed by general hyperthermia with hyperglycemia and adriamycin chemotherapy. This approach allows to prolong the survival to 5 years in 94.3 +/- 5.5% of patients with renal carcinoma and tumor occlusion in the veins as well as in 60.9 +/- 10.4% of patients with metastases to the regional lymph nodes. These results are significantly better than in surgical and combined treatment including radiation. Preoperative large-fraction radiotherapy (14 Gy) significantly increases 5-year survival of renal cancer patients with tumor thrombus in the renal vein or inferior vena cava from 26.9 +/- 12.0 to 63.5 +/- 13.5% (p < 0.05). Additional postoperative radiotherapy in 2Gy fractions to total dose 40 Gy fails to affect survival of the above patients. Combined treatment using preoperative large-fraction (14 Gy) and postoperative radiation in routine fractions (40 Gy) significantly improves 5-year survival against surgical treatment (22.2 +/- 7.1 and 5.4 +/- 3.8%, respectively) in patients with renal carcinoma metastasizing to regional lymph nodes. Large-fraction preoperative radiotherapy only in these patients adds little to the treatment efficacy.

[The prognosis of the treatment results in patients with operable kidney cancer]

Computer processing by 73 characteristics in the system "host-tumor" was performed for 322 patients operated on for renal carcinoma from 1976 to 1986. The automatic classification method or cluster-analysis allowed distribution of the patients into homogeneous preoperative and postoperative groups (classes) which differed by the mean of the signs in the classes, survival and response to treatment. The formulas have been derived that enable the clinicians to refer the patients to a certain prognostic group without using a computer. This suggests more grounded examinations and treatment policy.

[The effect of preoperative radiotherapy using high-energy radiation on the pathomorphosis of kidney cancer]

The paper analyses the effect produced by some preoperative treatments on the degree and depth of tumor cell lesion in 5 groups of patients with renal cell carcinoma. Group 1 consisted of 80 patients who had a surgical treatment alone and were studied for natural pathomorphism. Group 2 comprised 250 patients who had preoperative large-fractional radiation therapy in a total dose of 20 Gy. There was a partial suppression of mitotic and amitotic activities, more profound changes in organellae, particularly in mitochondria, nucleus, nucleolus, even destruction of individual cell elements as compared to the control group. Group 3 included 110 patients who had preoperative superfractional radiation therapy in a total dose of 14 Gy. The therapeutic pathomorphism of renal cell carcinoma was characterized by more profound and extensive changes in tumor cells as compared to Group 2. Group 4 involved 10 patients who underwent renal artery embolization. The letter led to the similar changes in tumor tissue as in Group 2. Particularly marked and extensive dystrophic and necrotic changes in tumor cells were observed in 35 patients who were enrolled into Group 5 and had preoperative renal artery embolization in combination with superfractional radiation therapy. The preoperative treatment techniques failed, however, to cause a total tumor parenchymal death as depending on the mode of preoperative therapy, the slightly damaged tumor cells were revealed in greater or lower quantities.

[The late results of the combined treatment of kidney cancer patients]

Randomized study with inclusion of certain types of immunotherapy in the schedule of complex treatment was conducted in 89 patients with kidney carcinoma after the operation. In 63 patients the tumor was in stage T3N0M0. The patients were separated into 4 groups after the operation. Group 1 consisted of 23 patients in whom no additional therapeutic measures were applied in the postoperative period; 8-year survival was 48%. Group 2 was made up of 23 patients who received immunotherapy with the BCG vaccine in the postoperative period; 8-year survival was 60.5%. Group 3 consisted of 9 patients who were given levamisole for immunotherapy in the postoperative period; 8-year survival was 44%. Group 4 consisted of 8 patients who were treated by a combined method in the postoperative period: administration of the BCG vaccine, a placental suspension, and cyclophosphamide; 8-year survival was 75%. Multiple metastases occurred in 26 patients. Nineteen patients did not receive additional treatment in the postoperative period; 2 patients survived for 1 year, none of the patients lived longer than 2 years. Seven patients were given immunotherapy with the BCG vaccine in the postoperative period; 6 patients survived 1 year, 4 patients--2 years. Measures for increasing the activity of the immune and macrophagal systems should be included in the schedule of complex treatment for patients with carcinoma of the kidney.